The AHA Guidelines and Scientifi c Statements Handbook
rates has not been shown to drive the improvement
in mortality. Furthermore, such reporting has failed
to effectively guide consumers or alter clinicians’
referral practices [1].
Hospital environment
Strategies to ensure consistent excellent care in
patients undergoing coronary surgery have evolved.
The most effective strategies include establishing
specialized heart centers, forming multidisciplinary
teams in hospitals, and creating and implementing
pathways, algorithms, and specifi c protocols devel-
oped with surgeon input. Well-designed clinical
pathways assist in delivering care by optimizing
resource utilization, minimizing chance of error,
and allowing for the reinvention of these standards
within the context of local culture [1].
Economic issues
Cost-effectiveness of CABG
CABG is cost-effective in the subgroups of patients
in whom survival and symptomatic benefi t is demon-
strable (Table 7.2). The most reasonable system of
analysis for cost-effectiveness of CABG is an estima-
tion of the dollars spent per quality-adjusted life year
gained ($/QALY), and a cost-effectiveness of $20 000
to $40 000/QALY is consistent with other medical
programs funded by society, such as hemodialysis
and hypertension treatment [1].Cost comparison with angioplasty
The initial cost of angioplasty is 50% to 65% of the
initial cost of CABG. The incremental cost of
repeated procedures during the follow-up period
had led to a cumulative cost of angioplasty that
approaches the cumulative of CABG at three years
[1]. The use of drug-eluting stents will require a re-
evaluation of cost-effectiveness considerations. The
initial procedure is more expensive than angioplasty,
sometimes approaching CABG in many patients
with multivessel disease [1].Indications
Asymptomatic or mild angina
Class I
1 CABG should be performed in patients with
asymptomatic or mild angina who have signifi cant
left main coronary artery stenosis. (Level of Evidence:
A)
2 CABG should be performed in patients with
asymptomatic or mild angina who have left main
equivalent: signifi cant (greater than or equal to
70%) stenosis of the proximal LAD and proximal
left circumfl ex artery. (Level of Evidence: A)
3 CABG is useful in patients with asymptomatic
ischemia or mild angina who have 3-vessel disease.
(Survival benefi t is greater in patients with abnormal
LV function; e.g., EF less than 0.50 and/or large areas
of demonstrable myocardial ischemia.) (Level of Evi-
dence: C)Class IIa
CABG can be benefi cial for patients with asymp-
tomatic or mild angina who have proximal LAD
stenosis with 1- or 2-vessel disease. (This recom-
mendation becomes a Class I if extensive ischemia
is documented by noninvasive study and/or LVEF is
less than 0.50.) (Level of Evidence: A)Class IIb
CABG may be considered for patients with asymp-
tomatic or mild angina who have 1- or 2-vessel
disease not involving the proximal LAD. (If a large
area of viable myocardium and high-risk criteria areTable 7.2 Cost per quality-adjusted life-year ($/QALY) of
revascularization compared with medical therapy*
CABG for left main stenosis, with or without angina 9,000
CABG for 3VD with or without angina 18,000
CABG for 2VD with severe angina and LAD stenosis 22,000
CABG for 2VD with severe angina, no LAD disease 61,000
CABG for 2VD, no angina, with LAD stenosis 27,000
CABG for 2VD, no angina, no LAD disease 680,000
CABG for 1VD, severe angina 73,000
PTCA for 1VD, severe angina 9,000
PTCA for LAD stenosis, mild angina 92,000
CABG indicates coronary artery bypass graft; 1, 2, or 3VD, 1-, 2-, or 3-vessel
disease; LAD, left anterior descending coronary artery; and PTCA, percutaneous
transluminal coronary angioplasty.
- Adjusted to 1993 dollars from multiple sources in a review by Kupersmith
et al. Prog Cardiovasc Dis. 1995;37:307–56.